Killing Pain: Fewer Opioid Scripts

Doctors and other health providers wrote about 11 million fewer prescriptions for narcotic painkillers in 2013 than in 2012, but some experts expected a bigger drop-off given the brighter spotlight on the nation's opioid epidemic.

In 2013, there were 230 million prescriptions for opioids such as Vicodin, OxyContin and Percocet, according to data from IMS Health, a drug market research firm. That represents about a 5% drop from a year earlier when 241 million were written.

On Wednesday, a coalition of more than 40, reform-minded groups and individuals asked FDA Commissioner Margaret Hamburg to revoke the agency's approval of Zohydro.

"In the midst of a severe drug epidemic fueled by over prescribing of opioids, the very last thing this country needs is a new dangerous, high-dose opioid," they wrote.

Most experts say the declines over the last 2 years are evidence of a flattening, rather than a clear downward trend.

"It's certainly a good thing, but I'm surprised the numbers haven't dropped more dramatically," said Lewis Nelson, MD, an emergency physician at NYU Medical Center. "Especially since there are many more regulatory efforts in place."

Over the last 15 years, use of prescription painkillers has ballooned, prompting federal officials to warn of an "epidemic" of addiction to these drugs. In 2010, there were about 16,650 overdose deaths tied to prescription opioids – more than a four-fold increase from the 4,030 deaths in 1999, according to the CDC.

Band-aid or Solution?

The Obama administration responded to the problem in 2011, calling for greater use of prescription drug monitoring programs, (PDMPs), drug take-back programs and tighter prescribing controls.

States have taken initiative on PDMPs, and among them New York stands out for the passage of its I-STOP bill in 2012, which requires doctors to check the electronic system before prescribing opioids.

"In the vast majority of states, they're underutilized, and it can be hard to interpret the results," Nelson said. For instance, it can be challenging to tell the difference between a patient who genuinely needs high-dose, high-volume prescriptions versus someone who is doctor shopping.

Funding is a major challenge, as is a lack of information sharing across state lines. In border regions, patients who buy in one state will not be recorded by the other state's monitoring program.

Nelson cautioned that the impact of PDMPs and other legislation shouldn't be downplayed. The 11-million drop in scripts suggests that something is working, he said -- and it could be greater prescriber awareness.

"Physicians are starting to use these agents in a more appropriate manner for medical conditions," said Michael Jann, a pharmacologist at the University of North Texas who has studied opioid abuse.

Since the early 2000's, reports and other guidelines encouraged clinicians to screen for and treat chronic pain.

At the same time, increases in opioid followed pharmaceutical industry funding of nonprofit groups and prominent doctors who advocated for more liberalized use of the drugs -- practices chronicled in reports by the Milwaukee Journal Sentinel and MedPage Today.

Pill Counts

The drop in opioid prescriptions from 2012 to 2013 represents a change, but what is not known is what has happened to the potency of prescriptions, said Len Paulozzi, MD, MPH, a medical epidemiologist and physician with the CDC.

For instance, the data does not look at the number of pills in each prescription. That's important because some prescriptions may be for a few days, such as for a dental procedure, while others may be for a month or more, for a chronic pain condition such as low back pain.

The data also does not take into account the dosage of each prescription, which can vary from a few milligrams per pill to 80 milligrams per pill.

Other research indicates that while opioid prescriptions increased throughout the 2000s, so too did the dose of each pill.

For instance, in a 2012 study, Paulozzi and other CDC researchers found that the average size of an oxycodone prescription -- the entire amount in the bottle -- increased from the equivalent of 923 milligrams of morphine in 2000 to 1,566 milligrams of morphine in 2010. Oxycodone is a commonly prescribed opioid and is the narcotic used in OxyContin.

For hydrocodone, the opioid used in Vicodin, the average dose per prescription increased from the equivalent of 170 milligrams of morphine in 2000 to 288 milligrams in 2010.

Whether that trend continued through 21012 and 2013 is not known. As a result, the new data from IMS doesn't necessarily mean Americans are consuming lesser amounts of opioids.

The FDA has also updated labeling on opioids so use of the drugs would be limited to patients with severe pain dearth of data showing the drugs are safe and effective for long-term chronic pain.

A Gateway to Heroin

If prescription opioid use is sliding, researchers are asking whether their abuse is being replaced by another highly addictive opiate: heroin.

In a Feb. 11 press briefing, White House drug czar Gil Kerlikowske and Wilson Compton of the National Institute on Drug Abuse said that while overall heroin abuse and deaths remain rare, there are signals that the narcotic's popularity is growing.

National data showed that in 2007 about 373,000 Americans reported using heroin in the previous year, compared with 669,000 in 2012. And just over 3,000 heroin overdose deaths were reported in 2010.

Seizures of heroin at the southwest border have jumped 324% between 2008 and 2013, Kerlikowske said.

Kerlikowske noted a recent study showing that 80% of new heroin users previously had used prescription painkillers recreationally.

"It is clear we cannot arrest our way out of the drug problem," he said at the briefing. "Science has shown us that drug addiction is a disease of the brain – a disease that can be prevented, treated, and from which one can recover."

"The pathway appears to be moving from prescription drugs to heroin, a very dangerous development," added Compton. "Heroin is cheaper in many parts of the country ... it's often a great surprise to the users themselves. Few people using prescription drugs expect to go on to develop heroin addiction."

Addiction specialists will be watching these developments closely over the next few years, Nelson said, with hopes that prescriptions for opioids continue to slide -- without a bump in heroin use.

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